Silent and Overlooked: Children With Selective Mutism

In February, a partnership of 17 mental health organizations published a report calling for an investment in school-based mental health to address the complex and growing mental health needs of today’s youth. This is long overdue.

After two long years of the pandemic, young children with anxiety and their parents grapple with the fallout from a long period of isolation and limited socialization opportunities. For many, COVID safety precautions restricted indoor playdates.

Winter weather made outdoor playdates challenging. And these same children have often struggled to cope with busy daycare and preschool settings after two formative years in the quiet of their homes during the pandemic.

Not surprisingly, a 2020 survey of 1,000 parents around the country reported that 69 percent of parents said the pandemic was the worst thing to happen to their child. And rates of anxiety in children have doubled since the pandemic.

Problems can be particularly pronounced. As a child psychologist, I often hear stories such as:

My 4-year-old son hasn’t spoken at his preschool since he started in the fall. He listens and follows instructions, but spends the entire day in silence. In contrast, his speech comes tumbling out as he exits the school building. He is talkative and expressive at home, but when he is at school, he is mute. Not one word, all day, every day.

For some children with an inhibited temperament, fear and avoidance become entrenched, and a problematic pattern of behavior develops. Selective mutism is a severe anxiety disorder characterized by an inability to speak in certain social settings, such as with teachers and peers at school, extended family, and in public settings.

Selective mutism affects roughly 1 in 140 children, although this is believed to be an underestimate. The disorder interferes with the child’s ability to develop age-appropriate social relationships, demonstrate knowledge, participate in activities, and advocate for their needs. Without effective treatment, behavioral patterns often become further ingrained over time and, as such, harder to treat.

Unfortunately, as many parents quickly learn, there are few providers and schools that understand selective mutism and how to intervene effectively. Only 4 percent of U.S. clinical psychologists are child clinicians, according to the American Psychological Association, and even fewer specialize in treating selective mutism. Typically, only 2 to 10 specialists are listed per state on a website devoted to education and outreach for the disorder.

Specialists who do treat the disorder often have long waitlists. Many do not accept insurance, making it difficult for lower-income families to find appropriate care.

To add to the challenges of families seeking appropriate and effective care, many therapists now offer telehealth-only support. This format is not ideal for young children who need practice speaking in various social settings.

And while many therapists function within their boundaries of competence, others take on cases outside of their areas of expertise without engaging in the training necessary to apply evidence-based approaches.

Some may apply their preferred therapeutic modality when it is not research-supported. As a result, seeking help can lead to long-term therapeutic work without progress.

For parents seeking support within the school system, the battle can be just as difficult. To be sure, there is a tremendous burden on our school systems in meeting the needs of children with mental health conditions, and resources are scarce.

Nationwide, schools have a shortage of psychologists, with only one school psychologist for every 1,211 students, despite recommendations from the National Association of School Psychologists (NASP) for a ratio of 1 school psychologist per 500 students.

Even when properly staffed, schools typically lack expertise in identifying and understanding disorders like selective mutism. Some may advise parents that their child will outgrow the problem, or they reduce expectations to increase comfort and allow other avenues for participation.

For example, teachers may praise and reinforce the use of gestures and picture cards to communicate needs. A dry erase board may be offered for the child to write his answers down.

Unfortunately, the child often learns that all or most of his needs can be met through nonverbal communication. “This daily, accumulated avoidance chips away at one’s self-efficacy,” says Steven Kurtz, Ph.D., an internationally recognized expert in the treatment of selective mutism.

Reasons for Hope

Despite the challenges, there is a reason for hope as our country calls for increased action and attention to child mental health issues. In December, the Surgeon General issued an advisory to highlight the urgent need to address the child mental health crisis, calling for a “swift and coordinated response.”

In his State of the Union address in March, President Biden announced a national mental health strategy that would double the number of school-based mental health professionals, train a diverse group of professionals, and create an integrated system of mental health support. This comes on the heels of a series of congressional hearings in February that brought attention to the youth crisis to identify and address barriers to care.

Last but not least, a partnership of 17 mental health organizations published a report in February calling for an investment in school-based mental health to address the complex and growing needs of today’s youth. The Hopeful Futures Campaign provides the first state-specific report card that examines actions each state has taken to promote school mental health and suggests concrete policy recommendations to better support youth mental health.

Recommendations include increased access to school counselors, partnerships with community mental health professionals, training in mental health for teachers, and wellness screenings. These measures would offer huge dividends for children with selective mutism.

Below are some key action steps and concrete recommendations that schools, communities, and policymakers can consider to improve children's lives and therapeutic outcomes with selective mutism.

Early Identification within Schools

Early intervention is key. It improves immediate outcomes and prevents problems from becoming increasingly complicated and harder to treat over time. In the treatment of selective mutism, early childhood educators are uniquely positioned to identify and bring these concerns to light, given that symptoms most commonly occur within the school environment.

As such, they require training to recognize the signs and symptoms of selective mutism. And increasing resources for early evaluation and screening programs will allow avenues to refer children who have demonstrated a consistent pattern of non-speech.

Community Partnerships and Training for Professionals

Once a child has been identified, embedding treatment within the context of the problems is critical (most commonly in the school). Developing and delivering an effective intervention plan often requires partnering with a specialist in the community who can provide training and consultation to school staff.

Within the school, a key worker can be designated to coordinate and maintain responsibility for implementing intervention goals and collecting data on progress in consultation with a multi-disciplinary team.

Intervention needs to be consistent, involving regular practice and an evolving set of goals. As such, improved access to and opportunities for training in evidence-based care are direly needed for schools and community mental health providers to increase their competencies in addressing conditions such as selective mutism.

The Florida International University (MINT) Anxiety Program researches the treatment of SM and offers a list of books, toolkits, resource guides, and training videos for teachers and mental health professionals. Books such as Overcoming Selective Mutism by Aimee Kotrba offer step-by-step guides for implementing intervention plans for children with SM.

Attention to Research

The dissemination of and training in evidence-based intervention is also essential. Recent research from the University of British Columbia Children’s Hospital suggests that parent-child interaction therapy for selective mutism (PCIT-SM) is an approach that combines play therapy and behavioral principles to maximize opportunities for child verbalization while eliminating adult behaviors that support avoidance, is effective in treating children with selective mutism.

In this approach, the child “warms up” to new people and social contexts through a series of carefully crafted steps often referred to as a “fade in.” This is followed by the gradual integration of new individuals into the play, and a slow increase of expectations in the form of specific speech prompts. As the child builds confidence, bravery practices move to new individuals, contexts, and activities.

Conclusion

In sum, while child mental health issues such as selective mutism can be challenging, these problems are not insurmountable. Public attention and advocacy that leads to increased funding will provide schools and communities with the proper resources to help these children succeed.

In partnership with increased training and knowledge among mental health professionals, children with selective mutism will not be left to struggle in silence. Unlocking their potential by addressing selective mutism early and effectively can radically change the trajectory of their social, emotional, and educational development.

To find a therapist, visit the Psychology Today Therapy Directory.